Infant Cereal Program
What Can We do Better?
Vesselina Petkova, RD
Canada Prenatal Nutrition Program (CPNP)
• No disclosures or conflicts of interest
• Will discuss process, barriers, and some
outcomes related to infant cereal program
• Project in progress
– Not an example of a perfect program
– Sometimes more questions than answers
– Share with you and get feedback
What is Iron Deficiency Anemia
• When low iron in the system = iron deficiency anemia (IDA)
– Ferritin is the measure of body’s iron storage
– Low iron store if ferritin < 12 ng/mL
• Lack of iron interferes with ability to create haemoglobin (Hg)
– Anemia when Hg less than 2 s.d.
– Usually when Hg < 110 g / L
• Hg responsible for distributing oxygen to
tissue, including heart and brain
Why does IDA matter
• Negatively affects billions worldwide
• Affects cognition, psychomotor development,
work productivity and community capacity
• High economic burden
– Highest costing disease (other than TB)
• Generally preventable
• Damage caused by IDA can be permanent if not
Infant Risk factors for IDA include:
• Pregnancy outcomes (mothers’ anemic, low birth
weight, premature infants)
• Rapid growth – infancy (6-24 m.o.)
• Nutrition behaviours / poor intake of iron:
– Early discontinuation of breastfeeding
– Poor nutritional status (food insecurity, low SES)
– Low iron formula
– Excessive / early cow’s milk intake
– Delayed / improper introduction of solids
Is it a problem in Nunavut?
• At least 250 cases of anemia in children (0-
5) managed and treated annually.
– ~ 50 cases per 1000 children/year (~ 5 %)
• True burden of the disease?
– Vast majority of patients are asymptomatic.
– Tip of the iceberg phenomenon
Many more unknown cases?
• Population screening provides proper prevalence.
– No screening protocol implemented across the Territory.
• Prevalence in Igloolik:
– 48% had anemia
– 28% had IDA - up to 8 x national averages!
– 53% depleted iron stores
Infant Screening in Iqaluit
• 6 m.o. - 5 y.o.
• 2006 – May 2010
• N = 677, but 1291 readings
70% of anemia is mild
Anemia by age group
Age in Months
Iqaluit Anemia Screening
• Prevalence rates are very high
– Highest at 8 – 11 months.
– If analysis is limited to infants < 24 months, then
42.7% of infants were anemic.
– Majority is mild.
– But 17% of the children had at least one reading
below 100 g/L (moderate anemia)
• Only 53 / 118 (~45%) patients went for venous
blood work to confirm diagnosis
• 30% of those who went for blood work did not
have a ferritin done to establish iron storage
Infant Cereal Supplementation
1. Context and Background
4. Outcomes and Feedback
Objective: Reduce the Prevalence of IDA
in Infants and Children
• Step 1: identify IDA as a public
– “By 2013, the rate of anemia in infants
and toddlers will be halved”
• Step 2: commit to a focused strategy in order to
– IDA program
Nunavut Iron Deficiency Anemia Project
Evaluation Strategy 2008
Food-Based Intervention Options
Considered ease of implementation, safety
profile of a product, cost, and availability.
1. Fresh meats, including country food
2. Jarred meats distribution
3. Infant cereal distribution
4. Vitamin supplementation
1. Provide iron-fortified infant cereal to Nunavut infants
from 6-12 months of age, in quantity sufficient to
meet the Recommended Dietary Allowance of 11
mg/day for iron.
2. Deliver cereal to infants via collaboration between
community-based CPNP projects and Health Centers
3. Determine if iron-fortified infant cereal is acceptable
to mothers and infants.
1st phase: 2009-2010
• Provision of cereal
– Through CPNP community based programs, with
support of local Health Centers
– 15 communities around Nunavut
• Order and distribution of cereal
– Partnership with Northwest Company
Cost and Funding
• Need: average of 3 boxes per month per child
x 6 months
• Cost of cereal: ~ $5/box (incl. shipping)
• ~ $ 90 per child
• Total cost: $60,000 provided by CPNP
– CPNP workers’ time and wages not included
Evaluation of 1st Phase
• Feedback from CPNP workers and mothers
who received cereal.
– # of boxes of cereal distributed
– # of users & who used cereal
– perspective of CPNP workers
• Acceptability of cereal
• All 15 communities received cereal.
• Very few provided detailed information on
– Systematic tracking wasn’t implemented
– Some workers simply stated – ‘most’ distributed
• Also not clear on the number of users
• Unexpected issues related to program success
such as Heinz recall of unrelated product
CPNP Workers’ Perspective
• Most centers found the program easy to
• A request for ‘not so much paper work’
– Asked to track how many users and how many boxes
distributed at a time
• “I got it but never opened it… I didn’t know
what to do with it”
CPNP Workers’ Perspective
• There was a major stress with where to keep
the cereal stock
• General request for fewer boxes
– Knowing there is an expiry date
– Feeling responsible for complete distribution
Acceptable to Children?
• 50% like, 30% neutral, 20% dislike taste
– Some mothers say children won’t eat it
– “My child doesn’t like the flavor, can we get
• 50% of mothers admit to sharing cereal
with other members of household
– Typically sibling outside age group
Acceptable to Mothers?
• 100% mothers support CPNP program to
• 75% would purchase cereal if available
Feedback from CPNP workers:
– “some mothers feel uncomfortable taking the
cereal… almost implying they were poor and
couldn’t afford the cereal”
– Felt that some mothers used it but not as the
predominant infant food source
• Iron fortified infant cereal is one part of
decreasing iron deficiency anemia amongst
• Program helps with broader goals of food
• Accepted by most mothers and infants
• General support for program and its continuation
• Fully implement cereal program
– In all communities
– Integrated in regular CPNP programming
– Address barriers (storage, summer break...)
• Continue to develop education and
• Evaluate health outcomes
– implementation of screening program
• How to better integrate program with
• How to integrate with local store?
• Are there locally sustainable options using
• What to do with anemia that is NOT iron
CPNP community workers
Mothers who provided feedback
Public Health Nutritionists